PRAMS Stillbirth Survey

[NCCDPHP] Pregnancy Risk Assessment Monitoring System (PRAMS)

Documents and Forms

Document Name Document Type
PRAMS Stillbirth Survey Form and Instruction
PRAMS Stillbirth Mail Questionnaire (English) Att 9a - PRAMS UT Stillbirth Questionnaire Mail_ENGLISH.pdf Form and Instruction
PRAMS Stillbirth Mail Questionnaire (Spanish) Att 9b - PRAMS UT Stillbirth Questionnaire Mail_SPANISH.pdf Form and Instruction
PRAMS Stillbirth Phone Questionnaire (English) Att 9c - PRAMS UT Stillbirth Phone Questionnaire_ENGLISH.docx Form and Instruction
PRAMS Stillbirth Phone Questionnaire (Spanish) Att 9d - PRAMS UT Stillbirth Phone Questionnaire_SPANISH.docx Form and Instruction
Att 12c - Stillbirth Mail Introduction and Informed Consent_ENGLISH.docx PRAMS Stillbirth Mail Introduction and Informed Consent (English) IC Document
Att 12d - Stillbirth Mail Introduction and Informed Consent - SPANISH.docx PRAMS Stillbirth Mail Introduction and Informed Consent (Spanish) IC Document

Information Collection (IC) Details

IC Title:	PRAMS Stillbirth Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	None	PRAMS Stillbirth Mail Questionnaire (English)	Att 9a - PRAMS UT Stillbirth Questionnaire Mail_ENGLISH.pdf	No	Paper Only
Form and Instruction	None	PRAMS Stillbirth Mail Questionnaire (Spanish)	Att 9b - PRAMS UT Stillbirth Questionnaire Mail_SPANISH.pdf	No	Paper Only
Form and Instruction	None	PRAMS Stillbirth Phone Questionnaire (English)	Att 9c - PRAMS UT Stillbirth Phone Questionnaire_ENGLISH.docx	No	Paper Only
Form and Instruction	None	PRAMS Stillbirth Phone Questionnaire (Spanish)	Att 9d - PRAMS UT Stillbirth Phone Questionnaire_SPANISH.docx	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies	FR Citation: 51 FR 42484

Number of Respondents: 160	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
PRAMS Stillbirth Mail Introduction and Informed Consent (English)	Att 12c - Stillbirth Mail Introduction and Informed Consent_ENGLISH.docx	11/29/2022
PRAMS Stillbirth Mail Introduction and Informed Consent (Spanish)	Att 12d - Stillbirth Mail Introduction and Informed Consent - SPANISH.docx	11/29/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.